All Entries Tagged With: "documentation"

Take 10 steps to refresh your documentation review process

Ensure your CDI programs examines patient records "door-to-door."

I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic manner. With that in mind, I thought I would share my perspective on how to approach a review.

I recommend a review methodology that goes from door-to-door: beginning with the ED record and ending with the discharge summary. As you review the chart, think about the disease processes you see. If you are an RN CDI professional, think about this just as if you were taking care of that patient on the nursing unit. Consider how these disease processes interrelate and affect that patient’s care. Now you need to make that clinical picture fit the regulatory requirements through compliant, codeable language.

Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.

Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?

Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you think the principal diagnosis is at this (albeit early) point? Also identify any early, potentially relevant secondary diagnoses. If the H&P is missing, make yourself a note to keep looking for it. If consults have been ordered, or you are expecting a consult to be ordered, make a note to look for the reports. Do you see a clinical picture without a diagnosis that might require a query?

Tip: Remember that when the chart is coded, the H&P and the discharge summary are going to carry the most weight.

Step 3: Look at vital signs and intake and output (I&O). Vital signs can give a strong clue in many cases as to just how sick your patient might be. You definitely need to note abnormals. I&O can help you if you’re looking for signs of acute renal failure due to dehydration, for instance. Determine if there are there any clinical conditions you might associate with the abnormal vital signs, such as a post-operative fever. Do you have enough supporting documentation to ask the physician if he or she suspects clinically significant atelectasis? Remember that when you evaluate for sepsis, fever is one of your SIRS indicators.

Step 4: Review labs and radiology reports. If there are abnormal findings, consider the clinical significance of those findings for the patient’s care. If the physician hasn’t addressed the abnormal findings in his or her documentation, make a note of those findings and follow the patient’s progression in future tests. As a CDI specialist, you may note a clinical progression based on those test results. Coders cannot code directly from labs or radiology reports, so if there is evidence of something clinically significant to report, query the physician. For instance, a patient with documentation of a subdural hematoma, mental status changes, and a decrease in their Glasgow coma scale may have had a brain MRI indicating mass effect and a midline shift. In this case you would probably query the physician regarding possible brain compression.

[more]

Q&A: Maryland CDI network answers member’s renal failure documentation inquiry

Q: If the physician documents throughout the record that the patient has acute renal failure (ARF)—he documents this in emergency department notes, history and physical, admitting diagnosis, and in the progress notes but fails to add it to the discharge summary—would the coder be allowed to pick up the acute renal failure and code for it or would the coder leave it out and until the CDI specialist queries the physician for documentation in the discharge note?

Additionally, if the physician documents ARF in the initial consult note while the patient was still in the emergency department and it is documented in the chart by the attending physician and the renal consult but the hospitalist who last saw the patient documents renal insufficiency in discharge summary, would you leave out the ARF completely just code the renal insufficiency or would you query the hospitalist?

A: “Oftentimes, diagnoses throughout the patient’s stay are left out of the discharge summary and yet are still coded, if there is documentation in the record to support those diagnoses.” states Lillian Keane, RN, BSN, CPC, documentation specialist at MedStar Health Good Samaritan Hospital.

Keane suggests also reviewing the labs (creatinine, glomerular filtration rate [GFR]) and using the RIFLE (risk, injury, failure, loss, end-stage kidney disease [ESKD]) classification published by the Acute Dialysis Quality Initiative (ADQI) group to assist in diagnosis of ARF.

In regard to the second scenario, Keane favors querying the physician for clarification since so many physicians use the term acute renal insufficiency and ARF as one and the same. “If the diagnosis of ARF is inconsistent with the RIFLE and there is conflicting documentation, I will query at that point,” says Keane.

“We also see the terms acute renal failure and acute renal injury used interchangeably at our facility,” says Cathy DeNoble, BS, RHIA, CCS, LPN, coordinator of Case Mix Information Management and CDI specialist at Johns Hopkins Health System in Baltimore. “They are easily misinterpreted acronyms with various definitions.  At our facility the attending is the final word and when in doubt…query never assume.”

Understanding the difference between the physician’s mindset and the coding rules, presents an educational opportunity, says Keane, who presented physician education sessions on RIFLE classification, differentiating acute renal insufficiency versus ARF versus azotemia and also the stages of chronic kidney disease.

Keane cites the September 2010 article of the month AKI: The Crossroads of ICD-9-CM and Medical Literature by James S. Kennedy, MD, as one resource, other resources on the ACDIS website include:

• Consider NKF definitions when documenting renal disease
• Column: AKI and the mess we’re in
• Acute kidney injury: The crossroads of ICD-9-CM and medical literature
• Q&A: Two query alternatives for acute on chronic renal insufficiency
• Use kidney key-words to sooth your documentation troubles
• Sample queries and educational posters in the Forms & Tools Library

Editor’s Note: Special thanks to The Maryland Hospital Association Clinical Documentation Improvement Workgroup for sharing this exchange. For information about joining Maryland’s networking events contact Christine Mobley, RN, director of clinical documentation at Prince George’s Hospital Center, at christine.Mobley@dimensionshealth.org.

Book Excerpt: Documentation needs to support severity of illness for pulmonary edema

Documentation Strategies to Support Severity of Illness, Second Edition

Fluid in the interstitial spaces in the lung or fluid in the alveoli can be interpreted as pulmonary edema. With severe shortness of breath, it is likely acute pulmonary edema. Chronic pulmonary edema is usually a manifestation of end-stage heart failure. Patients with acute pulmonary edema may present with acute respiratory failure.

Cardiac causes of acute pulmonary edema include:

• Exacerbation of left ventricular heart failure with volume overload in end-stage renal disease (ESRD) patients who have chronic heart failure
• Acute MI whether from coronary occlusion or demand MI
• Accelerated (or malignant) hypertension including the severe hypertension that may occur with thyrotoxicosis, pheochromocytoma, carcinoid syncrome, eclampsia
• Tachyarrhythmia (AF with RVR, supraventricular tachycardia, ventricular tachycardia)
• Takotsubo syndrome (stress cardiomyopathy or apical ballooning syndrome)

Non-cardiac causes of acute pulmonary edema include:

• Pulmonary embolism (venus thrombi, fat or air embolism)
• Aspiration of gastric acid
• Sepsis (ARDS)
• Rapid decompression
• Drowning
• Volume overload in ESRD patients who do not have chronic heart failure

Documentation needs

Was this an acute MI (including non-Q wave MI due to ventricular tachycardia, pulmonary embolism, or fat embolus? If so, document it as the cause of the pulmonary edema.

Was there chest trauma, rapid deceleration, sepsis, or ARDS? If so, document that as the cause of the pulmonary edema.

Did the patient aspirate fumes, vapors, gastric acid, or food? If so, document that as the cause of the pulmonary edema.

Is this volume overload related to renal failure with an otherwise stable heart? If so, document it as non-cardiac pulmonary edema.

If this is an ESRD patient with heart failure due to volume overload, state so. For example, write: “Noncompliant patient missed dialysis two days ago, admitted now in volume overload causing exacerbation of chronic diastolic heart failure.”

Editor’s Note: This excerpt was adapted from Documentation Strategies to Support Severity of Illness: Ensure an Accurate Professional Profile, second edition, written by ACDIS Advisory Board member Robert S. Gold, MD.

Book Excerpt: Tips for hypertension documentation

The 2012 edition of The CDI Pocket Guide was recently released.

The term “accelerated” hypertension is an archaic term but necessary for the correct documentation and coding of severe hypertension when it occurs as a secondary diagnosis. Unfortunately, coding terminology hasn’t caught up with the currently-accepted clinical diagnostic terms for severe, uncontrolled hypertension.

Terms such as “hypertensive emergency,” “hypertensive crisis,” “hypertensive urgency,” “severe hypertension,” “malignant hypertension,” and “accelerated hypertension” are all used in the literature and often overlap. Yet “accelerated,” and “malignant,” or “necrotizing” hypertension are the only terms that will result in coding as a comorbidity/complication: 401.0 or Categories 402-405 with 4th digit = 0.

Using only the terms “hypertensive emergency,” “hypertensive crisis,” and/or “hypertensive urgency,” will result in assignment of non-specific hypertension codes that do not accurately reflect the seriousness of the patient’s condition or the complexity of care required to treat it.

Clinical definition: A patient with hypertension that is consistent with “accelerated” or “malignat” should require urgent treatment (either IV or STAT oral dosing), have the same risks and clinical implications as urget or emergent hypertension and meet one of the following criteria:

• Systolic blood pressure (BP) > 180 mm Hg, or
• Diastolic BP > 110 mm Hg, or
• End-organ involvement/damage (e.g., neurologic, renal, or cardiac damage)

The following examples compares the criteria for accelerated hypertension with the more current terminology:

• “Hypertensive urgency” is defined as having BP > 180/110 mm Hg, with or without symptoms such as severe headache, shortness of breath and anxiety; and no end-organ involvement.
• “Hypertensive emergency” is usually symptomatic with BP of at least > 180/120 mm Hg; often it exceeds 22/140 mm Hg. There is end-organ involvement, with possible symptoms including chest pain and neurologic deficits.
• “Hypertensive crisis” is used to describe the spectrum of severe, uncontrolled hypertension that includes both urgent and emergent hypertension, as described above.

Editor’s Note: This excerpt was taken from The 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS and Cynthia L. Tang, RHIA, CCS.

Book Excerpt: Cor pulmonale

Another condition often misrepresented in clinical documentation is cor pulmonale. Cor pulmonale is failure of the right side of the heart secondary to increased pulmonary artery pressures usually due to underlying COPD. To be classified as cor pulmonale, the cause must originate int eh pulmonary circulation system. Symptoms mimic those of right-side heart failure and include:

• Enlarged right ventricle and pulmonary artery (per x-ray)
  

  The CCDS Exam Study Guide

• Tall, peaked P waves in the face of low QRS voltage
• EKG indicating right axis deviation
• Pulmonary function tests confirming underlying lung disease
• An echo cardiogram indicating right ventricular dilation with normal ventricular function

Typically, patients suffering from this condition o not have a primary cardiac condition yet they present with classic right-side CHF symptoms. Treatment is directed at the pulmonary process but may also include salt restriction, diuretics, oxygen, antihypertensives, and dobutamine. Cor pulmonale should be specified as either acute (exacerbation) or chronic. Clarification of physician documentation may become necessary when treatment of a patient with COPD exacerbation includes diuretics and the patient has no history of cardiac disease or CHF.

Editor’s Note: The CCDS Exam Study Guide prepares candidates for the Certified Clinical Documentation Specialist (CCDS) exam. It follows the content outline established by the advisory board that created the certification exam. Each chapter reviews clinical documentation improvement program principles and contains sample questions for self-testing.

The CDI evolution

By Juanita B. Seel RN, CCDS

I have been a CDI specialist for seven years. I wanted to share with all of you how our program has evolved throughout the years.

Looking for ways to grow your program?

When we first started our program in 2004, it was all about capturing the CCs (there were no MCCs at that time). It focused on moving the DRG to a higher weighted category. Physicians always asked, “How much money will this earn for the hospital?” We were called the “chart police,” “green sheet ladies” (our queries are bright green), and many more things I am sure.

I did not like the fact that we were seen as only trying to get more money for the hospital. To me, my job meant more than that. It was about capturing the true severity of illness of the patient being treated; it was about the most accurate risk of mortality being captured. It was about having the medical record stand on its own without the need to question diagnoses and codes for the record.

Fortunately, a few of the RN CDI specialists I worked with felt the same way. We soon started our own little movement to shift our focus away from DRG capture and to query the physician for any diagnosis not adequately documented in the chart—even if it actually lowered the DRG. We started looking for the consistency of documentation, the clarity of documentation, the correct description of diagnoses and clinical data to support all of these in the medical record.

When MS-DRG’s hit, we became more assured this was the way we wanted our program to be. I changed the way I presented information to physicians and focused more on clear, concise, and accurate documentation. I focused more on “you documented this, but did you really mean this.”

Our CDI department quit singling out queries for diagnoses that would raise the DRG to a higher level. We queried the physician for any diagnoses for which documentation was unclear, vague, or just plain not documented well. Our percentage of queries went from 15% to 35%. Our goal was to have the medical record stand up against any audit or review as far as documentation was concerned. We wanted to make sure the treatment plan matched clinically with the diagnoses in the medical record.

The strange thing was that when we did this, when we concentrated more on the accurate documentation, the money came. Our CMI stabilized (with a healthy fluctuation); our risk of mortality rates stabilized, and our severity of illness clearly indicated the illnesses—both acute and chronic—the patient was treated for. Physicians began to see us in a different light. We could discuss, sometimes at length, why the “coding language was so different from the medical language.”

Our program now has an 85% query response rate. We write an average of 700 queries a month, with an average chart review rate of 2,400 charts per month. We have a staff of five full time RNs, two part-time RNs, and one supervisor. We review charts at the main hospital and two outlying facilities. Our hospital has 700+ beds and the outlying bed total is about 125.

I am very proud of our program and how it has evolved. The point is, if a program will review the record based on the medical documentation matching the coding language needed, teach physicians what is needed in documentation and concentrate on the accurate documentation of all diagnoses in the medical record—not just CCs and MCCs—the money will come naturally, and auditors will not be taking away codes because of documentation issues.

Please feel free to contact me about our program. I love to brag about the work of our CDI specialists.

Editor’s Note: Juanita B. Seel RN, CCDS, is the Documentation Integrity Supervisor at Greenville (SC) Hospital System University Medical Center and current co-leader of the South Carolina ACDIS Chapter. This article was originally published on the DCBA blog “CDI Talk” and is reprinted here with permission. Contact her at JSeel@ghs.org.

Tip: Target documentation for respiratory infection with ventilator support

Pay strict attention to physician documentation before assigning a respiratory system diagnosis—particularly respiratory failure—as

Respiratory failure requires specific documentation.

the principal diagnosis, says William E. Haik, MD, FCCP, a pulmonologist and director of DRG Review, Inc., in Fort Walton Beach, FL, in a January interview with Briefings on Coding Compliance Strategies. The article was part of series which highlighted documentation and coding requirements regarding Recovery Audit Contractors’ (RAC) target areas as illustrated in the special edition MedLearn Matters article SE1028.

ICD-9-CM guidelines say that code 518.81 (acute respiratory failure) “may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital.” Don’t be tempted to report respiratory failure—or any other respiratory diagnosis—as principal when it’s clearly not the case, advises Haik. For example, when a patient has pneumonia and heart failure present on admission, don’t assume the pneumonia is principal simply because it would yield a higher-weighted DRG. If the patient receives an oral antibiotic for the pneumonia and an IV with diuretics to treat the heart failure, the heart failure is the principal diagnosis. That’s because the heart failure necessitates admission to the hospital, he explains.

“It’s sometimes very hard to tell whether from the documentation exactly when a patient goes into respiratory failure,” says Kathy DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at AHIMA in Chicago. “Were they admitted with it, or were they admitted with an exacerbation of congestive heart failure that progressed into respiratory failure 24 hours later?”

ICD-9-CM Official Guidelines for Coding and Reporting indicates that it is unusual for two diagnoses to equally meet the criteria for principal diagnosis, says DeVault. The guidelines instruct coders to look at both the circumstances of admission and the clinical treatment and diagnostic workup or therapy provided. When documentation is unclear regarding whether acute respiratory failure and another condition are equally responsible for occasioning the admission, CDI specialists can help the HIM team by querying physicians for clarification, she says.

Editor’s note: This article was published in the January issue of Briefings on Coding Compliance Strategies.

Book Excerpt: Bacteremia vs. Septicemia vs. Sepsis/SIRS

The Physician Queries Handbook

Editor’s Note: Since Dr. Gold was talking about sepsis vs. SIRS in his Q&A yesterday I thought I’d pull this item from the Physician Queries Handbook for further clarification.

Bacteremia is defined in the Textbook of Infectious Disease as “cultivatable bacteria in the bloodstream evidenced by a positive blood culture” with an emphasis that it may be transient and inconsequential. ICD-9-CM codes bacteremia as a symptom code that can never be a principal diagnosis when associated with an underlying infection.

Septicemia is defined in the Textbook of Internal Medicine as the presence of microbes (not just bacteria but also fungi or viruses) or toxins in the blood. The ICD-9-CM Official Guidelines for Coding and Reporting supports this definition by stating that septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms, which can include bacteria, viruses, fungi or other organisms, or toxins in the blood. Patients with septicemia are more severe or “sicker” than patients with bacteremia, given that Medicare-severity (MS)-DRGs consider bacteremia to be a complication and comorbidity (CC) and septicemia to be a major complication and comorbidity (MCC).

Typically, clinical indicators suggesting that a patient has sepsis (discussed later in this chapter) support septicemia; however, although every patient with sepsis has septicemia, not all patients with septicemia develop sepsis. Even so, bacteremic patients with the following symptoms may be considered to be septicemic:

• Temperature over 38.3°C (101°F) or less than 36°C (96°F)
• Pulse over 90/min.
• Respirations over 20/min. or a pCO2 of less than 32 mm Hg
• White blood cell counts of over 12,000 or less than < 4000
• Normal white blood counts with a differential count of over 10% bands (bandemia)

Since toxins, such as interleukin-1, interleukin-8, tumor necrosis factor, and the like, can result in septicemia, positive blood cultures are not required to diagnose septicemia and are, in fact, quite often negative.

Interestingly, many physicians or medical journal editors may consider the term “septicemia” to be archaic. The Textbook of Infectious Disease opted to eliminate a definition of septicemia in its most recent edition in 2005. Likewise, the International Sepsis Definition Conferences do not use the term “septicemia” in their official position statements, preferring the term “sepsis” or “systemic inflammatory response syndrome.” Nevertheless, Coding Clinic for ICD-9-CM explained in its fourth quarter 2003 issue that the Cooperating Parties opted to retain the term “septicemia” due to its incorporation in ICD-9 and to preserve statistical database integrity.

Sepsis is defined by the 2001 International Sepsis Definitions Conference to be the Systemic Inflammatory Response Syndrome (SIRS) due to an infection. Sepsis definitions have also been promulgated for pediatric and burn patients.

Clinical parameters listed by these committees are nonspecific and are intended to support a seasoned clinician’s intuition that a patient is septic. These include those noted above for septicemia as well as altered mental status, ileus, or evidence of organ dysfunction. Consequently, the physician should indicate in his or her clinical description that the patient is toxic or septic appearing, not a well-developed, well-nourished, non–toxic-appearing individual in no acute distress, if he or she intends to indicate that the patient has sepsis.

The treating physician must decide how these indicators factor in when determining whether a patient is septic or if they are due to other disease entities (e.g., elevated white counts due to steroids) and support these in documentation. CDI specialists should consult with their medical librarians, PubMed, or possibly Google or Bing to learn about these defining indicators and negotiate clinical significance with their treating physicians.

Severe sepsis and septic shock

Severe sepsis is sepsis associated with organ dysfunction, such as hypoxemia, ileus, altered mental status, thrombocytopenia, or an elevation of the prothrombin time. Note that severe sepsis does not require organ failure, only organ dysfunction.

Septic shock is tissue hypoperfusion due to sepsis, usually manifested by refractory hypotension (a fall of the systolic blood pressure of more than 40 mm Hg from baseline or to less than 90 mm Hg), either lasting more than one hour or unresponsive to fluid resuscitation associated with evidence of tissue ischemia, such as oliguria, metabolic acidosis, clammy extremities, or limb cyanosis. Treatment entails treating the underlying cause and often using norepinephrine (Levophed®) or high-dose dopamine.

Q&A: Searching for the principal diagnosis

Don't get sent to the principal's office for lack of principal diagnosis specificity.

Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal diagnosis? Am I limited to the simple back pain or can the coder chose the neck mass?

A: UHDDS guidelines define the principal diagnosis as “the condition determined by the physician, after study, to be chiefly responsible for the patient’s admission to the hospital for care.” This particular question is somewhat difficult to answer, however, without the complete medical record as a reference. The actual documentation will ultimately determine the principal diagnosis.

The following are just a few questions raised by the scenario described:

• What treatment was rendered?
• Was there a definitive surgical procedure related to a particular diagnosis?
• Are there secondary conditions present?
• Paresis
• Hemiparesis
• Neuropathy
• Neurogenic bowel / bladder
• Foot drop
• Other neuro condition
• Did the problem seem more orthopedic or neurologic?  Those issues with spinal cord impairment typically go to neurologic conditions when coded, and those without spinal cord impairment typically code to orthopedic.

If the documentation clearly links the symptoms at admission (i.e., back pain) to the newly diagnosed neck mass, then you could assign a principal diagnosis code for the mass. From the information relayed here, there might also be an opportunity to further clarify the type of mass: Is it a malignant neoplasm or tumor of the spine? The principal diagnosis could be the newly identified mass, but the physician would need to clearly document the link, i.e., “back pain/neurologic dysfunction due to _____ neck mass (whatever the final pathologists’ report is).”

The key in this case is whether the physician establishes the clear linkage in the chart that the back pain has been found to be due to the neck mass.  If that is done, the neck mass would then be the appropriate principle diagnosis.  Otherwise, “back pain” is it and that would be unfortunate.  “The condition determined . . . after study” (the neck mass) is the principle diagnosis as long as the linkage to the presenting symptoms is there.

So, my advice is to look closely at what the notes say, otherwise you might be stuck with “back pain.”

Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, and Trey LaCharite, MD, UT Hospitalists, at the University of Tennessee in Knoxville Clachari@UTMCK.EDU answered this question.

Clear, concise, precise use of language

Clear language has become a presidential priority? Where does CDI leave its mark?

“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a few years ago, and remember chuckling at the best and worst examples of effective communication.

Most CDI professionals no doubt would be surprised that an organization such as The Center for Plain Language exists. Many would also find it surprising to learn that President Barack Obama signed The Plain Writing Act of 2010 into law back in October and that the Office of Management and Budget recently drafted preliminary guidance for implementation of the new legislation. The law “requires the federal government to write all new publications, forms, and publicly distributed documents in a ‘clear, concise, well-organized’ manner that follows the best practices of plain language writing.”

The idea, of course, is that a well-informed public can better abide by, and influence promulgation of, the rules and regulations of their society. Such an ideal seems simple enough, and worthy enough, yet when applied to the profession of CDI, the complicated nature of this endeavor reveals itself.

Let me explain.

At its most elemental, the CDI specialist serves as translator between healthcare’s clinical and coding languages. Each of these languages has developed over many decades and is complete with its own rules and nuances of use.

Physicians spend in excess of 10 years of schooling learning the language of the body’s processes and the latinate words we use to describe those processes. What cardiologists are able to quickly communicate to each other may not be as easily understood if, for example, a cardiologist attempted to communicate a clinical scenario with a nephrologist. The language each type of physician uses may be precise to his or her own awareness of the conditions and according to the familiarity of how those words and phrases are used in their daily lives.

Although the language of medical coding may not have its history rooted in ancient Greek, it nevertheless dates back to the early 1800s when the first International List of Causes of Death (then called the Bertillon Classification of Causes of Death) was adopted by the International Statistical Institute at a meeting in Chicago, according to The HIM Director’s Guide to ICD-10. Since then, the International Classification of Diseases (ICD) has evolved through 10 revisions and contains not only more than 150,000 codes, but multiple details of instructions in the Official Guidelines for Coding and Reporting regarding the application of those codes.

Add to all this the complexity of transmitting the coded elements of healthcare information electronically to a variety of entities, including research agencies, government and private payers, physicians, and yes, sometimes even to the patients themselves. To do this, the American National Standards Institute (ANSI) Transaction Version 5010 and National Council for Prescription Drug Programs (NCPDP) Version DO and 3.0 needs to be implemented, which includes more than 850 structural, technical, and content changes to the current system.

Where is the simplicity of “plain language”?

Bear with me, please, as I am not quite done outlining the complexity of dialogue which currently governs our healthcare system. In several recent conversations, CDI professionals have expressed their frustration with CDI involvement in the planning for, and implementation of, electronic health records.

Depending on how precise your awareness is of this process, you may not know, for example, that an electronic health record (EHR) is not the same thing as an electronic medical record (EMR). An EHR is the global term encompassing all electronically-generated components of a computer-based patient record. It generally refers to hospital- or facility-based records, as opposed to the EMR, which is the global term encompassing all electronically-generated components of a computer-based patient record—generally refers to physician-, professional-, or clinic-based records. (Read more on these definitions in a previous blog post.)

All of this would (could? should? does?) make the indoctrinated individual’s mind recoil at the complexity of it all. And yet, this is the world CDI specialists enter every day as they attempt to translate missing or vague physician documentation into as precise a collection of words as possible to illustrate the clinical condition of the patients under their purview.

Every year, The Center for Plain Language calls for nominations for its ClearMark Award. Unfortunately, CDI as a profession would not be eligible. I am sure, however, that those in this field labor to follow the Center’s basic premise that:

• “Plain language is information that is focused on readers. When you write in plain language, you create information that works well for the people who use it, whether online or in print.
• Plain language is behavioral: Can the people who are the audience for the material quickly and easily find what they need, understand what they find, and act appropriately on that understanding?”

At its best, a well-implemented CDI program will help the physician use plain and precise language throughout the medical record so that everyone who needs to use that information—from nurses to coders, from IT to billing, and even from physicians to their patients—can understand and use that information.